8500APPLICANT TOFILL iN|
I
INSPECTOR COPY
CITY ELECTRIC PEPIMIT;F
CONTRACTORS
RESIDENTIAL 4.00
PANELS 10.00
u.A, 6 4 11, -PHONE
DATE OF APPLICATION
ARCHITECT
on
ENGINEER LIC. NO.
PANELS (OVER 200 AMP) 20.00
PLAN CHECK FEE P.C. NO.
'. a ,
SIGNS TRANS. 3.00
ARCH . OR ENG.
ADDRESS
ZIP
SPECIAL CIRCUIT 5.00
PERYT VALIDATION
TEMP. METER OR POLE INS. 20.00
APPLICANT 5
ADDRESS
MOTORS SEE FEE SCH.
ISERVICE CHANGE 20.00
LICENSED CONTRACTORS DECLARATION
TEMP. POLE 30.00
I hereby ffimn that I licensed under p,.si,i .... s of Chapter 9
ISSUANCE16ATE
(commencing with Section 7000) of Division 3 of tile Business and
Professions Code, and my license is in full force and effect
BLDG
-37,
ELECT.
PLO. MECH.
Date I I Contract.,
INFORMATION
OWNER -BUILDER DECLARATION
hereby affirm that I am exempt from the Corityactor's License
Law bottle following reason. (Sec. 7031.5. Business and Professions
Code: Any cilyor county which rvquircs� a permit to construct, alter,
improve, derrolish, or repair any structure. prior to its issuance. also
requires the applicant for such permit to file a signed statement that
he is licensed pursuant to the provisions of the Contractor's License
Law (Chapter 9 (commencing wRb Section 7000) ofDivision 3 ofthe
Business and Professions Code) or that he is exenipt therefrom and
MISC. REFER TO ORD
VALUAT17
$/FT.
PERMIT ISSUANCE 10.00
ELEC.CONTR. LIC. NO.
TE L ETC.
AL
PERRATTO
()TYI-PLUMBING PERMIT FEE
STORIES
TYPE CONSTR.
the basis for tile alleged exemption. Any violation ofSection 7031.5
by any applicant for a Pennit Subjects tire applicant to a civil pCoally
.fnot ... thao Five hundred dollars (5500).):
ALTER -DRAIN & VENT -WATER (EA.) 5.00
0 1. as owner of the property. or'my employees with wages as
their sole compensation, will do the work. and the structure is not
BACK FLOW PROTECT. DEVICE 4.00
OCC. GROUP
RES. UNITS
DRAINS -FLOOR, ROOF, AREA,CONQ 5.00
intended or offered for sale (Sec. 7044, Business and Professions
Code: The Contractor's License Law does hot apply 1. an coene, .1
P,-Pc,ty who builds or improves iliencon, and who does such work
himself or through his own employees, provided that such improve -
.Cut, are nor intended or offered for sale. 11, however, tile Finding
F IXTUR ES - PER TRAP 5.00
SQ. FT. -FLOOR AREA
TOTALACREAGE
GAS - EA. SYSTEM - 1 INC. 4 OUTLETS 6.00
or improvement is sold within one year (if completion, the owne '
buildic, will have tile burden of fp�ovio, that he did not build or im"
prove for purpose of sale.).
0 1, as Owner Of tile Property, all) exClUSIvely contracting with
GAS - EA. SYSTEM - OVER 4 (EA1 2.00
BUILDING USE
RES IND CON PB Other
El 0 El � 1:1 1:1
INDUSTRIAL WASTE INTER. 30.00
licensed contractors to on,QQct the p ... feet (Sec. 7044, Business
and Professions Code: The Contract,,,', License Law does not apply
to air owner Of Property who builds or improves theyeon. and who
LAWN SPRINKLERS - 1 INC 5 V.B. 6.00
LAWN SPRINKLERS - OVER 5 (EA.) 1.00
ASSESSORS PARCEL NO.
contracts for such profects with a contractor(s) licensed pinsuart I(
III, Contractor's License Law.
SEWER -SAN ITARY-STORM EA. 200tt/I 0.00
TRACT NO.
PARCEL NO!
reason
WATER HEATER W/VENT 6.00
Owner [)at,
WATER SYSTEM 5.00
ACC.DATE
ACC. FILE NO.
WATER TREATING EQUIP. 5.00
WORK ERS'COMPENSA FION DECLARAI [ON
or . cc,tilic.tc if Workers' C�n .... FF,ljoR In,, Ihn,e. OF a c,rttliod
ZONING
ENG. SITE NO.
copy thereof (See. 3800 Lab C.).
Policy No.- C.;CpaCY4,
3�, 14, P
FIRE SPRINK
ENERGY T-24
D Certified copy is hereby Ion
IF CA FE OXE) lils mON 17RONI WORKERS'
C
PERMIT ISSUANCE 10.00
FLOODZONE
A L.U.C.
dE COMPENSATI111N INSURANCE
tl not be econpleted it the emnt is for on,
PLG. CONTE. LIC. NO.
PL
hundred dollars IS 100) Or less.)
I certify that in tire neyforniance of the we k for which this per-
out is Rsued, I still Out employ any person i,'any lFanner so as o
CITY. ur MECHANICAL PERMIT FEE
FEE SUMMARY
BUILDING
become subject to tire WmTkers'Compensal ion Law,ofCAiI.miR
Date-Applicart
I
-
/ ALTER OR ADD TO MECH.
NoriCE TO APPLICANT: 11, after making (],is Certilic,te .1 E,.
emptum, you should become subject to tire Workers' Compensation
APPLIANCE 5.00
PLAN CHECK
provisions (if the Labor Code. you must torthwith comply with
such provisions or this permit shall be deemed revoked,
AIR HANDLING UNIT (TO 10SX10C.F.M.) 4.00
FEE
AIR HANDLING UNIT(OVER 10MOC.F.M.) 6.00
SEISMIC FEE
CONSTRUCI ION LENDING AGENCY
I hereby afforn tbat there is a construction lending agency for
EXHAUST HOOD (WITH DUCT) 5.00
the performance of the work for which this permit is issued (See.
MICROFILM
Lemiler', Name
L,ndc,', Add.,,
HEATING UNIT (OVER 100,000 B.T.U.)9.50
ELECTRIC
I certify that I have read this application unit state that tile above
VENTILATION FAN (SINGLE) 4.00
mfOrmation is correct. I agree to comply with all city and county
ordinances and state laws relating to building construction. and
PLUMBING
BOILER - COMP (� H.P. or 100,000 B.T.U.) 6.00
BOILER -COMP (Over 1100,0GO BTU) SEE FEE SCH.
MECHANICAL
hereby authoriLe representatives of this city to enter upon the
above-mentioned property for inspection putpoSes,
(We,) Fee to Save, indemnify and keep municss the City of
Cupertino most bilities, judgments, costs and CXPCnWS Who-
OF
7mayin an /wapraf-N-glt . Said City in consequence of tile
MISC. ! / 7 , /, . J REFER TO ORD.
CONST. TAX
RMIT ISSUANCE
PE 14,00
granting of per
__T
NIECH. CONT. LIC. NO.
MECH.
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INSPECTOR COPY